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Jiang X, Wang W, Lei L, Feng T, Hu Y, Liu P, Li Y, Sheng R, Zhang Y, Li S, Zhang J, Zhang Y, Jin ZG, Tian Z, Jiang J, Xu Y, Si S. Antirheumatic drug leflunomide attenuates atherosclerosis by regulating lipid metabolism and endothelial dysfunction via DHODH/AMPK signaling pathway. Int J Biol Sci 2024; 20:3725-3741. [PMID: 39113703 PMCID: PMC11302888 DOI: 10.7150/ijbs.93465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Accepted: 06/21/2024] [Indexed: 08/10/2024] Open
Abstract
The probability of cardiovascular events has been reported lower in rheumatoid arthritis (RA) patients treated with leflunomide. However, the anti-atherosclerotic and cardiovascular protective effects and metabolism of leflunomide are not explored. In this study, we assessed the potential benefits of leflunomide on atherosclerosis and revealed the underlying mechanism. ApoE-/- mice were fed a western diet (WD) alone or supplemented with leflunomide (20 mg/kg, oral gavage, once per day) for 12 weeks. Samples of the aorta, heart, liver, serum, and macrophages were collected. We found that leflunomide significantly reduced lesion size in both en-face aortas and aortic root in WD-fed ApoE-/- mice. Leflunomide also obviously improved dyslipidemia, reduced hepatic lipid content, and improved disorders of glucose and lipid metabolism in vivo. RNA-Seq results showed that leflunomide effectively regulated the genes' expression involved in the lipid metabolism pathway. Importantly, leflunomide significantly increased the phosphorylation levels of AMPKα and acetyl-CoA carboxylase (ACC) in vivo. Furthermore, leflunomide and its active metabolite teriflunomide suppressed lipid accumulation in free fatty acid (FFA)-induced AML12 cells and improved endothelial dysfunction in palmitic acid (PA)-induced HUVECs through activating AMPK signaling and inhibiting dihydroorotate dehydrogenase (DHODH) signaling pathway. We present evidence that leflunomide and teriflunomide ameliorate atherosclerosis by regulating lipid metabolism and endothelial dysfunction. Our findings suggest a promising use of antirheumatic small-molecule drugs leflunomide and teriflunomide for the treatment of atherosclerosis and related cardiovascular diseases (CVDs).
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Affiliation(s)
- Xinhai Jiang
- State Key Laboratory of Bioactive Substances and Functions of Natural Medicines, NHC Key Laboratory of Biotechnology for Antibiotics, National Center for New Microbial Drug Screening, Institute of Medicinal Biotechnology, Chinese Academy of Medical Sciences & Peking Union Medical College (CAMS&PUMC), No.1 Tiantan Xili, Beijing, 100050, China
| | - Weizhi Wang
- State Key Laboratory of Bioactive Substances and Functions of Natural Medicines, NHC Key Laboratory of Biotechnology for Antibiotics, National Center for New Microbial Drug Screening, Institute of Medicinal Biotechnology, Chinese Academy of Medical Sciences & Peking Union Medical College (CAMS&PUMC), No.1 Tiantan Xili, Beijing, 100050, China
| | - Lijuan Lei
- State Key Laboratory of Bioactive Substances and Functions of Natural Medicines, NHC Key Laboratory of Biotechnology for Antibiotics, National Center for New Microbial Drug Screening, Institute of Medicinal Biotechnology, Chinese Academy of Medical Sciences & Peking Union Medical College (CAMS&PUMC), No.1 Tiantan Xili, Beijing, 100050, China
| | - Tingting Feng
- Department of Clinical Pharmacy, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200000, China
| | - Yang Hu
- Pharmacy Department, Peking Union Medical College Hospital, PUMC & CAMS, Beijing, 100730, China
| | - Peng Liu
- State Key Laboratory of Bioactive Substances and Functions of Natural Medicines, NHC Key Laboratory of Biotechnology for Antibiotics, National Center for New Microbial Drug Screening, Institute of Medicinal Biotechnology, Chinese Academy of Medical Sciences & Peking Union Medical College (CAMS&PUMC), No.1 Tiantan Xili, Beijing, 100050, China
- Department of Medicine, Aab Cardiovascular Research Institute, University of Rochester School of Medicine and Dentistry, 601 Elmwood Ave, Box CVRI, Rochester, NY 14642, USA
| | - Yining Li
- State Key Laboratory of Bioactive Substances and Functions of Natural Medicines, NHC Key Laboratory of Biotechnology for Antibiotics, National Center for New Microbial Drug Screening, Institute of Medicinal Biotechnology, Chinese Academy of Medical Sciences & Peking Union Medical College (CAMS&PUMC), No.1 Tiantan Xili, Beijing, 100050, China
| | - Ren Sheng
- State Key Laboratory of Bioactive Substances and Functions of Natural Medicines, NHC Key Laboratory of Biotechnology for Antibiotics, National Center for New Microbial Drug Screening, Institute of Medicinal Biotechnology, Chinese Academy of Medical Sciences & Peking Union Medical College (CAMS&PUMC), No.1 Tiantan Xili, Beijing, 100050, China
| | - Yuyan Zhang
- State Key Laboratory of Bioactive Substances and Functions of Natural Medicines, NHC Key Laboratory of Biotechnology for Antibiotics, National Center for New Microbial Drug Screening, Institute of Medicinal Biotechnology, Chinese Academy of Medical Sciences & Peking Union Medical College (CAMS&PUMC), No.1 Tiantan Xili, Beijing, 100050, China
| | - Shunwang Li
- State Key Laboratory of Bioactive Substances and Functions of Natural Medicines, NHC Key Laboratory of Biotechnology for Antibiotics, National Center for New Microbial Drug Screening, Institute of Medicinal Biotechnology, Chinese Academy of Medical Sciences & Peking Union Medical College (CAMS&PUMC), No.1 Tiantan Xili, Beijing, 100050, China
| | - Jing Zhang
- State Key Laboratory of Bioactive Substances and Functions of Natural Medicines, NHC Key Laboratory of Biotechnology for Antibiotics, National Center for New Microbial Drug Screening, Institute of Medicinal Biotechnology, Chinese Academy of Medical Sciences & Peking Union Medical College (CAMS&PUMC), No.1 Tiantan Xili, Beijing, 100050, China
| | - Yuhao Zhang
- State Key Laboratory of Bioactive Substances and Functions of Natural Medicines, NHC Key Laboratory of Biotechnology for Antibiotics, National Center for New Microbial Drug Screening, Institute of Medicinal Biotechnology, Chinese Academy of Medical Sciences & Peking Union Medical College (CAMS&PUMC), No.1 Tiantan Xili, Beijing, 100050, China
| | - Zheng-gen Jin
- Department of Medicine, Aab Cardiovascular Research Institute, University of Rochester School of Medicine and Dentistry, 601 Elmwood Ave, Box CVRI, Rochester, NY 14642, USA
| | - Zhuang Tian
- Cardiology Department, Peking Union Medical College Hospital, PUMC & CAMS, No.1 Shuaifuyuan, Beijing, 100730, China
| | - Jiandong Jiang
- State Key Laboratory of Bioactive Substances and Functions of Natural Medicines, NHC Key Laboratory of Biotechnology for Antibiotics, National Center for New Microbial Drug Screening, Institute of Medicinal Biotechnology, Chinese Academy of Medical Sciences & Peking Union Medical College (CAMS&PUMC), No.1 Tiantan Xili, Beijing, 100050, China
| | - Yanni Xu
- State Key Laboratory of Bioactive Substances and Functions of Natural Medicines, NHC Key Laboratory of Biotechnology for Antibiotics, National Center for New Microbial Drug Screening, Institute of Medicinal Biotechnology, Chinese Academy of Medical Sciences & Peking Union Medical College (CAMS&PUMC), No.1 Tiantan Xili, Beijing, 100050, China
| | - Shuyi Si
- State Key Laboratory of Bioactive Substances and Functions of Natural Medicines, NHC Key Laboratory of Biotechnology for Antibiotics, National Center for New Microbial Drug Screening, Institute of Medicinal Biotechnology, Chinese Academy of Medical Sciences & Peking Union Medical College (CAMS&PUMC), No.1 Tiantan Xili, Beijing, 100050, China
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Kralj-Hans I, Li K, Wesek A, Lamorgese A, Omar F, Ranasinghe K, McGee M, Brack K, Li S, Aggarwal R, Bulle A, Kodre A, Sharma S, Fluck D, John I, Sharma P, Belsey JD, Li L, Seshasai SRK, Li HL, Marczin N, Chen Z. Leflunomide treatment for patients hospitalised with COVID-19: DEFEAT-COVID randomised controlled trial. BMJ Open 2023; 13:e068179. [PMID: 37055207 PMCID: PMC10105917 DOI: 10.1136/bmjopen-2022-068179] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/15/2023] Open
Abstract
OBJECTIVE To evaluate the clinical efficacy and safety of leflunomide (L) added to the standard-of-care (SOC) treatment in COVID-19 patients hospitalised with moderate/critical clinical symptoms. DESIGN Prospective, open-label, multicentre, stratified, randomised clinical trial. SETTING Five hospitals in UK and India, from September 2020 to May 2021. PARTICIPANTS Adults with PCR confirmed COVID-19 infection with moderate/critical symptoms within 15 days of onset. INTERVENTION Leflunomide 100 mg/day (3 days) followed by 10-20 mg/day (7 days) added to standard care. PRIMARY OUTCOMES The time to clinical improvement (TTCI) defined as two-point reduction on a clinical status scale or live discharge prior to 28 days; safety profile measured by the incidence of adverse events (AEs) within 28 days. RESULTS Eligible patients (n=214; age 56.3±14.9 years; 33% female) were randomised to SOC+L (n=104) and SOC group (n=110), stratified according to their clinical risk profile. TTCI was 7 vs 8 days in SOC+L vs SOC group (HR 1.317; 95% CI 0.980 to 1.768; p=0.070). Incidence of serious AEs was similar between the groups and none was attributed to leflunomide. In sensitivity analyses, excluding 10 patients not fulfilling the inclusion criteria and 3 who withdrew consent before leflunomide treatment, TTCI was 7 vs 8 days (HR 1.416, 95% CI 1.041 to 1.935; p=0.028), indicating a trend in favour of the intervention group. All-cause mortality rate was similar between groups, 9/104 vs 10/110. Duration of oxygen dependence was shorter in the SOC+L group being a median 6 days (IQR 4-8) compared with 7 days (IQR 5-10) in SOC group (p=0.047). CONCLUSION Leflunomide, added to the SOC treatment for COVID-19, was safe and well tolerated but had no major impact on clinical outcomes. It may shorten the time of oxygen dependence by 1 day and thereby improve TTCI/hospital discharge in moderately affected COVID-19 patients. TRIAL REGISTRATION NUMBERS EudraCT Number: 2020-002952-18, NCT05007678.
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Affiliation(s)
| | - Kuo Li
- Imperial College, London, UK
| | | | | | - Fatima Omar
- Ashford and Saint Peter's Hospitals NHS Trust, Chertsey, UK
| | | | - Megan McGee
- Ashford and Saint Peter's Hospitals NHS Trust, Chertsey, UK
| | - Kieran Brack
- Ashford and Saint Peter's Hospitals NHS Trust, Chertsey, UK
| | - Shiliang Li
- East China University of Science and Technology, Shanghai, China
| | | | - Ajay Bulle
- Meditrina Institute of Medical Science, Nagpur, India
| | | | - Shashank Sharma
- St Peters Hospital Emergency Department, Ashford and Saint Peter's Hospitals NHS Trust, Chertsey, UK
| | - David Fluck
- Cardiology, Ashford and Saint Peter's Hospitals NHS Trust, Chertsey, UK
| | - Isaac John
- Ashford and Saint Peter's Hospitals NHS Trust, Chertsey, UK
| | | | | | - Ling Li
- Department of Engineering, City University, London, UK
| | | | - Hong Lin Li
- Shanghai Key Laboratory of New Drug Design, Shanghai, China
| | | | - Zhong Chen
- Ashford and Saint Peter's Hospitals NHS Trust, Chertsey, UK
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Zheng K, Chen Y, Liu S, He C, Yang Y, Wu D, Wang L, Li M, Zeng X, Zhang F. Leflunomide: Traditional immunosuppressant with concurrent antiviral effects. Int J Rheum Dis 2023; 26:195-209. [PMID: 36371788 DOI: 10.1111/1756-185x.14491] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Revised: 10/06/2022] [Accepted: 10/24/2022] [Indexed: 11/15/2022]
Abstract
Leflunomide is a classic disease-modifying anti-rheumatic drug that is widely used to treat autoimmune diseases. Studies also show its antiviral effects in in vitro and/or in vivo experiments. Considering glucocorticoids, immunosuppressants and newly emerged antibodies commonly used in autoimmune diseases and autoinflammatory disorders bring risk of infection such as viral infection, leflunomide with combination of anti-viral and immunosuppressive features to maintain the balance between infection and anti-inflammation are attractive. Here we summarize the actions and mechanisms of leflunomide in immunoregulatory and antiviral effects.
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Affiliation(s)
- Kunyu Zheng
- Department of Rheumatology and Clinical Immunology, Chinese Academy of Medical Sciences & Peking Union Medical College; National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology; State Key Laboratory of Complex Severe and Rare Diseases, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Peking Union Medical College Hospital (PUMCH), Beijing, China
| | - Yiran Chen
- Department of Rheumatology and Clinical Immunology, Chinese Academy of Medical Sciences & Peking Union Medical College; National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology; State Key Laboratory of Complex Severe and Rare Diseases, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Peking Union Medical College Hospital (PUMCH), Beijing, China
| | - Suying Liu
- Department of Rheumatology and Clinical Immunology, Chinese Academy of Medical Sciences & Peking Union Medical College; National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology; State Key Laboratory of Complex Severe and Rare Diseases, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Peking Union Medical College Hospital (PUMCH), Beijing, China
| | - Chengmei He
- Department of Rheumatology and Clinical Immunology, Chinese Academy of Medical Sciences & Peking Union Medical College; National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology; State Key Laboratory of Complex Severe and Rare Diseases, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Peking Union Medical College Hospital (PUMCH), Beijing, China
| | - Yunjiao Yang
- Department of Rheumatology and Clinical Immunology, Chinese Academy of Medical Sciences & Peking Union Medical College; National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology; State Key Laboratory of Complex Severe and Rare Diseases, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Peking Union Medical College Hospital (PUMCH), Beijing, China
| | - Di Wu
- Department of Rheumatology and Clinical Immunology, Chinese Academy of Medical Sciences & Peking Union Medical College; National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology; State Key Laboratory of Complex Severe and Rare Diseases, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Peking Union Medical College Hospital (PUMCH), Beijing, China
| | - Li Wang
- Department of Rheumatology and Clinical Immunology, Chinese Academy of Medical Sciences & Peking Union Medical College; National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology; State Key Laboratory of Complex Severe and Rare Diseases, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Peking Union Medical College Hospital (PUMCH), Beijing, China
| | - Mengtao Li
- Department of Rheumatology and Clinical Immunology, Chinese Academy of Medical Sciences & Peking Union Medical College; National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology; State Key Laboratory of Complex Severe and Rare Diseases, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Peking Union Medical College Hospital (PUMCH), Beijing, China
| | - Xiaofeng Zeng
- Department of Rheumatology and Clinical Immunology, Chinese Academy of Medical Sciences & Peking Union Medical College; National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology; State Key Laboratory of Complex Severe and Rare Diseases, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Peking Union Medical College Hospital (PUMCH), Beijing, China
| | - Fengchun Zhang
- Department of Rheumatology and Clinical Immunology, Chinese Academy of Medical Sciences & Peking Union Medical College; National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology; State Key Laboratory of Complex Severe and Rare Diseases, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Peking Union Medical College Hospital (PUMCH), Beijing, China
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Kramarič J, Ješe R, Tomšič M, Rotar Ž, Hočevar A. COVID-19 among patients with giant cell arteritis: a single-centre observational study from Slovenia. Clin Rheumatol 2022; 41:2449-2456. [PMID: 35366735 PMCID: PMC8976457 DOI: 10.1007/s10067-022-06157-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 03/28/2022] [Accepted: 03/28/2022] [Indexed: 12/24/2022]
Abstract
OBJECTIVES Patients with giant cell arteritis (GCA) represent a fragile population with an increased infection risk. In a recent study, older age, a higher number of comorbidities, higher disease activity and prednisolone ≥ 10 mg/day were associated with worse COVID-19 outcome. We aimed to evaluate the frequency and severity of COVID-19 in a well-defined GCA cohort. METHODS We reviewed medical records of histologically and/or by imaging-proven GCA patients diagnosed between September 2011 and February 2020 at our secondary/tertiary centre and followed during the COVID-19 pandemic between March 2020 and February 2022 (24 months). Descriptive statistics were used to explore the studied population. RESULTS Of 314 patients with GCA diagnosed for the first time during a 102-month period, 49 patients died before March 2020. Of the remaining 265 patients, 55 (20.8%) patients suffered from a total of 57 SARS-CoV-2 infections. We observed 44 (77.2%) mild and 13 (22.8%) severe COVID-19 episodes (the latter defined as needing hospitalization, death or thrombotic complication). Patients with severe COVID-19 were more likely to have arterial hypertension (12 [92.3%] vs. 25 [56.8%]; p = 0.022), cardiovascular disease (7 [53.8%] vs. 10 [22.7%]; p = 0.043) or obesity (5 [38.5%] vs. 5 [11.4%]; p = 0.038). Neither prednisolone dose 1-5 mg/day (p = 0.483) nor leflunomide use (p = 1.000) was associated with COVID-19 course. There were no significant differences in sex, age, GCA type, GCA disease duration and other comorbidities in patients with mild and severe COVID-19 in our cohort. CONCLUSION More than a fifth of our GCA patients had severe COVID-19. Treatment with leflunomide or low doses of glucocorticoids were not associated with severe course in our cohort. Key Points • Treatment with leflunomide or low doses of glucocorticoids were not associated with worse COVID-19 outcome. • Outcomes of COVID-19 improved as the COVID-19 pandemic, prevention and treatment options evolved. • Arterial hypertension, cardiovascular disease or obesity were associated with severe COVID-19.
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Affiliation(s)
- Jelka Kramarič
- Department of Rheumatology, University Medical Centre Ljubljana, Vodnikova 62, 1000, Ljubljana, Slovenia.
| | - Rok Ješe
- Department of Rheumatology, University Medical Centre Ljubljana, Vodnikova 62, 1000, Ljubljana, Slovenia
| | - Matija Tomšič
- Department of Rheumatology, University Medical Centre Ljubljana, Vodnikova 62, 1000, Ljubljana, Slovenia
- Medical Faculty, University of Ljubljana, Ljubljana, Slovenia
| | - Žiga Rotar
- Department of Rheumatology, University Medical Centre Ljubljana, Vodnikova 62, 1000, Ljubljana, Slovenia
- Medical Faculty, University of Ljubljana, Ljubljana, Slovenia
| | - Alojzija Hočevar
- Department of Rheumatology, University Medical Centre Ljubljana, Vodnikova 62, 1000, Ljubljana, Slovenia
- Medical Faculty, University of Ljubljana, Ljubljana, Slovenia
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Significance of Immune Status of SARS-CoV-2 Infected Patients in Determining the Efficacy of Therapeutic Interventions. J Pers Med 2022; 12:jpm12030349. [PMID: 35330349 PMCID: PMC8955701 DOI: 10.3390/jpm12030349] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2021] [Revised: 02/12/2022] [Accepted: 02/14/2022] [Indexed: 12/15/2022] Open
Abstract
Coronavirus disease 2019 (COVID-19) is now being investigated for its distinctive patterns in the course of disease development which can be indicated with miscellaneous immune responses in infected individuals. Besides this series of investigations on the pathophysiology of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), significant fundamental immunological and physiological processes are indispensable to address clinical markers of COVID-19 disease and essential to identify or design effective therapeutics. Recent developments in the literature suggest that deficiency of type I interferon (IFN) in serum samples can be used to represent a severe progression of COVID-19 disease and can be used as the basis to develop combined immunotherapeutic strategies. Precise control over inflammatory response is a significant aspect of targeting viral infections. This account presents a brief review of the pathophysiological characteristics of the SARS-CoV-2 virus and the understanding of the immune status of infected patients. We further discuss the immune system’s interaction with the SARS-CoV-2 virus and their subsequent involvement of dysfunctional immune responses during the progression of the disease. Finally, we highlight some of the implications of the different approaches applicable in developing promising therapeutic interventions that redirect immunoregulation and viral infection.
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